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Briumvi — Medica

relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive multiple sclerosis) in adults

Preferred products

  • generic glatiramer injection
  • generic dimethyl fumarate delayed-release capsules
  • generic fingolimod capsules

Initial criteria

  • Patient meets the standard Multiple Sclerosis – Briumvi Prior Authorization Policy criteria; AND
  • Patient meets ONE of the following (i–vii):
  • i. Patient has been started on Briumvi; OR
  • ii. Patient meets BOTH of the following (a and b):
  • a) Patient has tried generic dimethyl fumarate delayed-release capsules; AND
  • b) Patient has experienced inadequate efficacy or significant intolerance, according to the prescriber; OR
  • Note: Prior use of Tecfidera, Bafiertam, or Vumerity with inadequate efficacy or significant intolerance (according to the prescriber) also counts; OR
  • iii. Patient meets BOTH of the following (a and b):
  • a) Patient has tried generic glatiramer injection; AND
  • b) Patient has experienced inadequate efficacy or significant intolerance, according to prescriber; OR
  • Note: Prior use of Copaxone or Glatopa with inadequate efficacy or significant intolerance (according to the prescriber) also counts; OR
  • iv. Patient meets BOTH of the following (a and b):
  • a) Patient has tried generic fingolimod capsules; AND
  • b) Patient has experienced inadequate efficacy or significant intolerance, according to the prescriber; OR
  • Note: Prior use of Gilenya or Tascenso ODT with inadequate efficacy or significant intolerance (according to the prescriber) also counts; OR
  • v. According to the prescriber, patient has experienced inadequate efficacy or significant intolerance to one of Ocrevus (ocrelizumab intravenous infusion), Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq subcutaneous injection), Kesimpta (ofatumumab subcutaneous injection), a natalizumab intravenous product (Tysabri, biosimilar), Mavenclad (cladribine tablets), or Lemtrada (alemtuzumab intravenous infusion); OR
  • vi. Patient has received Briumvi in the past; OR
  • vii. According to the prescriber, the patient has highly active or aggressive multiple sclerosis by meeting ONE of the following [(1)–(4)]:
  • (1) Patient has demonstrated rapidly advancing deterioration(s) in physical functioning [documentation required]; OR
  • (2) Disabling relapse(s) with suboptimal response to systemic corticosteroids [documentation required]; OR
  • (3) MRI suggests highly active or aggressive multiple sclerosis [documentation required]; OR
  • (4) Manifestations of multiple sclerosis-related cognitive impairment [documentation required]

Approval duration

1 year